Does Tourette’s Syndrome help Tim Howard?

For those of you who have been living under a rock for the past fortnight, the FIFA World Cup has been on. Unfortunately the US Men’s team was knocked out by Belgium in extra time on Tuesday, but if one man can hold his head high it is Tim Howard. The US goalkeeper made a record breaking 16 saves, and put in a man of the match performance.

Howard also suffers from Tourette’s syndrome; a neurological disorder characterized by physical and vocal tics [1]. Tics are sudden, nonrhythmic movements or vocalizations, usually repetitive using discrete muscle groups [2]. Whilst the specific cause of Tourette’s syndrome has not been identified, basal ganglia dysfunction and related perturbations to dopamine signalling are thought to play a major role [3]. Changes in anatomy have been seen in brains from those suffering from Tourette’s syndrome [4]. However, the role of these changes has not been identified [5], and it is not known if they are a cause or consequence of Tourette’s syndrome [6,7]. The prevalence of Tourette’s syndrome is not known exactly, with estimates that between 0.1-0.3% children are diagnosed with the condition [8,9].

Last year Howard was interviewed by German newspaper Der Spiegel where he spoke candidly about living with Tourette’s syndrome. Interestingly he credits his skills partially to his condition. “I realized I was faster than others when it came to certain movements, and that these reflexes were linked to my disorder.” Exercise has been linked with improving the rate of tics [10], but can it actually improve sporting ability as Howard suggests? Oliver Sacks previously described a story about a Tourette’s syndrome sufferer whose condition improved his reflexes and ability as a drummer, which was lost when the patient was treated with the anti-psychotic Haldol. This suggests that Tourette’s may be able to improve performance, but the full mechanism is not elucidated, and is currently under investigation.

Controlling Tourette’s syndrome with exercise

Patients with Tourette’s are usually able to contain their tics temporarily, but often undergo discomfort. To actively suppress tics can require a lot of concentration, and sufferers are usually encouraged to take part in something that will provide mental or physical distraction [11]; for example playing sports, a musical instrument, learning a foreign language, meditating or even playing video games [10,12,13]. These distractions allow patients to decrease the frequency of tics. Furthermore, it has been shown that preventing a single tic can help prevent the occurrence of other tics [14]. The majority of studies are unfortunately anecdotal and contain a small sample number, so the results must be taken with a pinch of salt, but they are promising nonetheless.

But how does this relate to improving sporting ability? A simple hypothesis may be due to the effects of exercise on stress levels. It has long been documented that exercise helps reduce stress, and under stressful conditions the frequency and severity of tics can increase [15]. Therefore, it makes sense that exercise can help decrease the number of tics. However, this doesn’t explain how people under immense stress, like Howard in a World Cup knockout game, are able to cope. Howard admits that he allows his tics when the ball is on the other side of the pitch, but “[a]s soon as things get serious in front of [the] goal, I don’t have any twitches; my muscles obey me then.”

Professor Georgina Jackson, from The University of Nottingham, has a hypothesis that when patients learn to control their tics they become extremely conscious of their actions and movements [16]. In order to gain control over their tics, it is possible that sufferers develop compensatory mechanisms [4,6]. It is possible that the anatomical differences seen in the brain of patients may be part of these mechanisms [4,17], and there is some evidence that these coping mechanisms may provide some benefits [18,19].

The benefits of Tourette’s syndrome?

In studies measuring high levels of cognitive control processes, adolescents suffering from Tourette’s syndrome performed significantly better than age-matched controls [18]. Participants were shown three boxes. A pre-determined light cue was shown in the center box, and a target appeared in one of the boxes to the left or right. Participants were told to either shift their eye movement to the box with a target (pro-saccade) or without (anti-saccade). Each type of experiment was preceded by a specific colour light signal. Those with Tourette’s made fewer mistakes and responded faster to the anti-saccade, suggesting enhanced cognitive control. Mueller et al. conclude that the chronic suppression of tics may result in increased control over reflexive behavior [18, below].

Here is the task used by Mueller et al, 2006. During a prosaccade trial, which was precued by a green border around the edges of the screen, an eye movement was required toward the target box appearing on either the left or right side. During an antisaccade trial, which was precued by a red border, an eye movement had to be made into the opposite direction to the target. On the right, you can see the results of the task, showing that on the switch trials, Tourette’s sufferers made less mistakes.

This has also been seen in adults, coupled with a linear relationship between increased tic suppression and improved cortical networks [4]. They are also thought to increase ability of attention-seeking tasks, including suppression of tics [20]. Although it is not fully understood if they are compensatory mechanism, these studies suggest that the coping mechanism basically grants “spidey-sense”, improving reflexes in response to unpredictable stimuli and allowing for improved performance at attention-seeking tasks.

As well as Tim Howard, ex-NBA player Mahmoud Abdul-Rauf has Tourette’s syndrome. Similarly he claims his condition helped him, although in a different manner. At least a third of patients suffering from Tourette’s syndrome also have obsessive-compulsive disorder (OCD) and two thirds have symptoms of attention deficit hyperactivity disorder (ADHD) [21,22]. Abdul-Rauf’s OCD helped him perfect his game, and when he concentrates on the task in hand his tics subside, possibly providing some evidence for Professor Jackson’s hypothesis. Other sportsmen with Tourette’s syndrome include ex-Major League Baseball player Jim Eisenreich and NASCAR driver Steve Wallace; both sports where quick reflexes would be a bonus.

Future work

At the moment there is no evidence for a causative relationship between tic suppression, altered brain anatomy and improved performance. These experiments must be carried out to determine how the anatomy of the brain is altered in Tourette’s syndrome; determining if the changes are a cause or consequence. Furthermore, the effects on reflex and performance must be thoroughly investigated to look for causation.

Importantly, the biochemical mechanism behind the improved cortical network must be determined, as repairing this network could have beneficial results on those suffering from Tourette’s. Even if it doesn’t lead to improved sports performance, the potential benefits on tic suppression would be huge. It is necessary to measure the cortical network over years, to see if it advances over time with improved suppression of tics. Usually the ability to prevent tics increases with age [23], possibly with the generation of the compensatory mechanism. Therefore, if tic suppression over years leads to anatomical changes, causation could be suggested. It would also be interesting to know if stimulating this mechanism could affect patients without Tourette’s syndrome, especially if it is capable of enhancing performances.

So, can Tourette’s syndrome improve performance? It seems the answer is…possibly, although more research is needed. Current evidence suggests that the coping mechanisms behind tic suppression may improve the diminished basal ganglia function and that these mechanisms may improve reflex speed and ability to carry out unpredictable tasks. As Professor Jackson says, “[t]his control mechanism… has benefits for your voluntary movements, whether it’s goalkeeping or at a laboratory level.” However, without evidence of a causative relationship it is impossible to state if Howard’s Tourette’s syndrome really helped him and his performance.

About the Writer – – – – –

Alex Ryan is a postdoctoral researcher at UCSD, based in the Endocrinology department. Alex’s research interests lie in the study of type 2 diabetes, in particular, the interplay between fat, skeletal muscle and the pancreas in the etiology of the disease. He received his PhD in physiology from the University of Manchester in 2013, studying the role of PIP2 in insulin resistance. If you ask nicely, he can present an award winning presentation on his work. He writes his own blog at alexvsscience.wordpress.com